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WHAT IS THIS?
Alopecia areata is a skin condition that can affect hair on the head or body and the nails. It is quite common as it affects 1.7% of people at some point in their lives. It is not a serious illness: it does not “hide” anything and there is no underlying illness causing it that doctors would need to look for.
WHAT DOES IT LOOK LIKE?
Alopecia areata can appear in the form of hairless patches that are usually round or oval; this is the most common form. Sometimes it starts at the back of the head and gradually spreads towards the sides and up above the ears (ophiasis pattern alopecia areata). More rarely, it can affect the whole head (alopecia totalis). If body hair is also affected this is known as alopecia universalis. The nails may show small dents that look like those on a thimble (pitting) or they may be damaged over a wider area, with a rough appearance as if they had been grated lengthways (trachyonychia). Any of the body’s hair structures can be affected individually: eyebrows, beard hair in men, some areas of body hair, and the hair loss may be patchy or widespread.
At the edges of the patches exclamation mark hairs can be seen, which are small broken hairs that are only a few millimetres long and loosen easily.
HOW DOES ALOPECIA AREATA PROGRESS?
Alopecia areata progresses in a very irregular manner.
The key thing to remember is that it occurs in episodes. Someone may have only one episode in their whole life, or they may have multiple episodes; they may be “undisturbed” for several years then develop a new episode for no reason. The episodes can vary in intensity, duration and in terms of extent of the hair loss. There are few signs that allow a doctor to assess the progression of alopecia areata because it is by definition an unpredictable and varying condition. However, it does seem to be acknowledged that if widespread alopecia areata appears in early childhood then there is a higher risk that it will get worse or that the patient will have severe further episodes. This is nonetheless only a statistic so it is not necessarily applicable to each individual. There are numerous intermediary stages and clinical and progressive forms, ranging from alopecia areata with one single hairless patch where the hair regrows spontaneously in two months to, much more rarely, alopecia universalis that does not change over many years.
ARE INVETIGATIONS NECESSARY?
Usually they are not. The only assessment will be the doctor’s clinical examination. However, your doctor may sometimes believe that it would be useful to take a specimen of blood, depending on the clinical signs, in order to check that you do not have another associated autoimmune disease: the reason for this is that alopecia areata is an autoimmune illness, so patients show a slightly greater predisposition for other autoimmune illnesses that are also common in the general population, such as illnesses of the thyroid gland. If it turns out that your thyroid gland is not working properly this can quickly be addressed using a simple treatment (although unfortunately this does not have any effect on the alopecia itself).
In addition to this, people who have alopecia areata are more susceptible to allergies, which means that they have a greater predisposition for eczema, asthma, and allergic rhinitis, conditions that are also common among the general population. These illnesses generally do not have any specific impact on alopecia areata.
A number of years ago, X-rays of the teeth used to be taken but now we know that interventions involving the teeth have no effect on alopecia areata.
IS IT CAUSED BY STRESS
There is no particular link between stress and alopecia areata: psychological factors and specifically “stress” are often cited by patients and their family or friends, and even by some doctors, as a cause of alopecia areata (and all too often for skin problems in general). We all know that connections exist between the mental state and the immune system (remember that as we have seen, alopecia areata is an autoimmune illness) and patients do sometimes notice a marked feeling of stress in the days and weeks before the first episode of alopecia begins. This phenomenon nonetheless does not have any statistical support and rigorous studies that have been carried out do not show any significant connection between a stressful event and a first episode of alopecia. Any psychological problems that might be found in association with alopecia areata are quite varied and sometimes they can be as a result of the alopecia itself.
DO I HAVE TO SEE A PYSCHOLOGIST?
There is no general rule. The goal of a consultation would not be to look for a psychological cause for alopecia areata, as explained above, but for the patient to feel more positive in spite of their condition, which can be very upsetting. Alopecia undoubtedly has an impact on mood, social and professional or school life, on relationships and on what is known as “quality of life”, and this varies depending on the type of alopecia and the person affected: their age, sex, origins, and personal history. A specialised opinion from a psychological therapist may be useful but referrals are not made routinely. This can be discussed with the doctor who is managing your alopecia areata.
WILL I PASS ALOPECIA AREATA ON MY CHILDREN?
There is a great deal of variation in terms of the risk of developing alopecia areata when another family member has a history of the condition, and this depends on which genes have been passed on. Of course, the situation is different when several closely related people within one family all have alopecia areata (for example a parent and a grandparent, and uncles or aunts) from cases when it seems to be an isolated phenomenon. It is thought that if one of the two parents has severe alopecia (totalis, universalis), then on average the risk to the child of developing alopecia areata at some point in their life is 6 % and the risk of developing severe alopecia is 2 %. However, if one monozygotic twin (“true twins”) has alopecia areata then the risk to the other twin is 55%.
IS ALOPECIA AREATA AN AUTOIMMUNE DISEASE?
Yes: certain kinds of white blood cells, especially particular types of lymphocytes, no longer recognise the end of the hair root, known as the bulb, as being a “normal” part of the body. They attack the bulb, surrounding it like a swarm of bees [Figure]. When a hair is attacked in this way it stops functioning and it breaks (these are the hairs known as “exclamation mark hairs”) then falls out leaving smooth skin behind with no visible hair shaft. However, the follicle is only blocked rather than destroyed so once the lymphocytes leave, whether this process is spontaneous or caused by treatment, the hair can function normally again. The problem is that lymphocytes are sometimes stubborn and plentiful, and that they act according to rules that doctors and researchers do not yet fully understand.
CAN HAIR REGROW BY ITSELF?
Yes, and this happens quite often in alopecia areata (in 60% of cases that affect up to 40% of the scalp) and it also happens, although less easily, in alopecia totalis and universalis. Of course the longer a patient has had alopecia areata and the more resistant it is to treatment, the lower the chances that hair will regrow spontaneously, and the higher are the risks of further episodes. Once again, this is based on statistical data but it does not always apply to every individual. If alopecia areata is not treated, this does not increase the risk of hair never regrowing. This means we must not be fixated on producing hair regrowth quickly and “at any cost”.
WHAT ARE THE CURRENT TREATMENTS?
Most of the current treatments aim at dispersing the white cells that attack the hair follicles. For now, the treatments available only have a temporary effect because new white cells appear over the course of the episode or in future episodes. We will not describe all of the treatments or explain their specific advantages, contraindications, side effects or potential risks, as you can discuss this with your doctor. Only you and your doctor can choose the best treatment for you to try. The most commonly used treatments are:
• Cortisone, which is a key treatment in inflammatory and autoimmune conditions. It can be:
— Applied topically (topical corticosteroid therapy). This is a straightforward treatment that does not pose any danger when used at the dose advised by your doctor. It has been shown to be useful and works on a number of types of alopecia, both in adults and children.
— Administered by local injections (the doctor injects the medicine into your skin) in adults, and only on a limited number of areas. After several weeks, this leads to hair regrowing in “tufts” in the areas that have been treated.
— Administered to reach the whole system, although only in special cases and for a limited duration. A specialist doctor will decide when this treatment is suitable.
• Preparations based on product derived from tar (anthralin = dithranol named also anthralin) can be applied to the affected areas of the scalp for a short time. This treatment does cause irritation.
• Minoxidil can cause thicker regrowth, but it has no effect on the mechanism that controls alopecia areata.
• Light therapy (usually PUVA therapy, which is a combination of a medicine called psoralen and rays of ultraviolet A light) is used for short periods that are decided upon by a dermatologist, and it takes place in a special booth. A specialist doctor will decide whether this treatment is suitable because it is not appropriate for everyone. UVB rays, lasers or Excimer 308 nm lamps are different types of light therapy, and they do not seem to work as well as PUVA therapy.
• Contact immunotherapy is a treatment that can be carried out in some specialist centres that consists of making patients allergic to a chemical substance (usually diphencyprone), which is then applied to the areas of alopecia areata. This creates eczema that can stimulate hair to regrow. It is only recommended in specific cases.
• Immunosuppressant medicine: methotrexate, taken as a tablet or injected into the muscles is also sometimes offered by a dermatologist for severe cases of alopecia areata or cases that are resistant to treatment.
• There are other treatments although their effects are debated or they have not been validated by any clinical studies carried out.
ARE THERE WAYS OF DISGUISING HAIR LOSS?
A hairpiece, or wig, may be useful for patients who have large areas of alopecia. If a wig is prescribed by a doctor then social security in France will partially reimburse the cost (to the amount of 125 €), and this is more or less the same for health insurance plans. The prices vary depending on the quality, the type of hair (synthetic or natural), the cap and the way in which the hair has been attached to the cap. It should be the case that, where justified, social security will cover reimbursement of two hairpieces per year.
Cosmetically tattooing on eyebrows or the exposed edge of the eyelids, especially for women, can be done by qualified professionals. If possible you should take photos from before you had alopecia so that they can see the shape of the eyebrows. Cosmetic tattooing does not block regrowth.
AND IS RESEARCH ONGOING?
There are many research teams working on this area across the world, addressing both its pathophysiology (the mechanisms that cause alopecia to appear) and methods of treatment. Every year numerous articles are published on alopecia in specialist scientific journals. Of course, they do not always have a rapid impact on the treatment of alopecia, which is your concern, but they do lead to small or large advances in our understanding and management of this illness.
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